J Ayub Med Coll Abbottabad 2015;27(2)

ORIGINAL ARICLE
RATE OF POSTERIOR CAPSULAR RENT AS A COMPLICATION OF
RESIDENT PERFORMED CATARACT EXTRACTION PROCEDURES
Ayesha Amin, Tahira Ayub, Sarah Samuel
Al Shifa Trust Eye Hospital, Rawalpindi, Department of Medical Education, Foundation University Medical College, Christian Hospital,
Taxilla-Pakistan

Background: Cataract extraction is the most commonly offered treatment for cataract. This is done
surgically by a number of methods which include extracapsular cataract extraction and
phacoemulsification. This study was done to assess the rate of posterior capsule rupture as a
complication of resident performed cataract extraction procedures. Methods: It is a descriptive case
series conducted from 1st March to 1st April 2014 at Al Shifa Trust Eye Hospital, a tertiary care
hospital. Cataract extraction procedures were done by first to fourth year residents. The surgical
procedures done were extracapsular cataract extraction, phacoemulsification and lens matter aspiration.
Results: A total of 577 cases were operated, 307 males and 270 females. Out of which 336 were right
eyes and 241 left eyes. The patients were in the age range 1780 years. Only 61 out of 577 cases had
posterior capsular rent. In phacoemulsification rate of posterior capsular rent was 29% and in
extracapsular cataract extraction 69%. According to the year of residency cases done by first year were
24, second year 131, third year 231 and fourth year 191 with posterior capsular rents in 3, 23, 5 and 30
cases respectively. A total of 11 cases were left aphakic, 10 after extracapsular cataract extraction and 1
after phacoemulsification. Conclusion: There is a relatively high rate of posterior capsular rupture in
cataract extraction procedures performed by residents. This rate is directly related to the procedure,
being low for phacoemulsification and high for extracapsular cataract extraction. Rate of posterior
capsular rupture is also directly related to the skill and expertise of the surgeon, being high for second
year residents as compared to third and fourth year residents.
Keywords: posterior capsular rupture, phacoemulsification, extracapsular cataract extraction,
cataract extraction procedures, residents
J Ayub Med Coll Abbottabad 2015;27(2):3046

INTRODUCTION MATERIAL AND METHODS

Age related cataract is the most common cause of
preventable blindness around the globe. The treatment
involves its removal by various surgical procedures
only.1 Various studies have been done worldwide to
observe the rate of complications in cataract extraction
procedures specially phacoemulsification. There have
also been studies comparing the rate of complications
among residents and faculty. The main focus has also
been on the resident learning curve which gradually
improves the skill and reduces the complications
rate.2,3
In Pakistan cataract extraction is the most
commonly done procedure by residents most common
technique being extracapsular cataract extraction
(ECCE) followed by phacoemulsification. Under
special circumstances lens matter aspiration (LMA) is
done. This study was done to compare the rate of
posterior capsular (PC) rent in phacoemulsification,
ECCE and LMA in uncomplicated cataract cases done
by residents from first to final year of residency. Such
studies are rarely done earlier in our part of the world
although it is a procedure done on daily basis
contributing to the major burden of work as most
commonly performed procedure for admitted patients
in the ophthalmology department.
It was a descriptive case series done for a period
of one month from 1st March to 1st April 2014 at
Al Shifa Trust Eye Hospital (ASTEH), a tertiary
care hospital in Rawalpindi after ethical approval.
Cataract extraction procedures were done by first
to fourth year residents.
The surgical procedures done were
ECCE, phacoemulsification and LMA. After
informed consent data was collected on a pro
forma and analysed using SPSS.
RESULTS
A total of 577 cataract extraction surgeries were
done. The patients were in the age range 1780
years. There were 307 (53.2%) males and 270
(46.8%) females.
Left eye of 241 patients and right eyes of
336 patients were operated upon. According to
the year of residency cases done by first year
were 24, second year 131, third year 231 and
fourth year 191 with PC rents in 03, 23, 05 and 30
cases respectively.
Frequency of PC rents was 61 (10.57%).
A total of 11 cases were left aphakic, 10 after
ECCE and 01 after phacoemulsification.

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 J Ayub Med Coll Abbottabad 2015;27(2)

DISCUSSION be caused by the relative increase in number of cases

being done by residents of that year. It is significant
According to statistics modern cataract surgery has
to note that although fourth year is the most senior
been considered to be safe in 95% of patients.5 If a
but maximum numbers of cases were done by third
complication occurs most common of it is an intra-
year (231) with PC rent in 8.1% of cases which is the
operative posterior capsular rupture.5 This may be
lowest for all years. The total number of cataract
considered a potentially serious complication because
cases being done by fourth year (191) decreased
it might account for a dropped nucleus, vitreous loss
because of an increase in the number of other
leading to retinal detachment, cystoid macular
specialty related cases. But the findings show that an
oedema and difficulties with placement of the
improvement in skill and increased experience cause
intraocular lens5, all of which can lead to a reduction
a decrease in number of complications. Such data can
in the final visual acuity.
be used to assess the resident learning curve.
At ASTEH cataract extraction using ECCE,
Among the various identified risk factors for
phacoemulsification and LMA is a routine. ECCE is the
PC rupture by The UK Cataract National Database of
most commonly used method by first and second year
Cataract Surgery, a major factor was junior surgeons
residents while all three methods are used by third and
performing the surgery.8 This goes in accordance
fourth year residents. ECCE is the first surgery among
with the findings in our study where second year
all to be started with by first year residents after an
residents experienced a high rent rate. Other
observation period followed by step by step progression
identified risk factors included increased age, male
towards supervised ECCE. As the experience and skill
gender, glaucoma, diabetic retinopathy, dense
improves the number of cases done by the resident
cataracts, pseudoexfoliation, vitreous opacities, small
increase with a fourth year resident doing maximum
pupil size, axial lengths of greater than 26mm and
surgeries. Normally all procedures include Intraocular
use of systemic medication like doxazocin.8
lens implantation as a protocol.
In another International study it was
A study was done at ASTEH to assess the
observed that the overall capsule rupture rate was
rate of posterior capsular rent in different cataract
1.8% and the residents had higher rates as compared
extraction procedures by first to fourth year residents.
to the faculty.4 In one study the overall incidence of
Among 577 patients it was observed that posterior
this complication was approximately 1% but was
capsular rent was the most common intra-operative
further reduced when the technique of capsulorhexis
complication with an incidence rate of 10.57%.
was mastered.6 In India in a retrospective study there
Relating to the type of procedure, the highest rate of
were more posterior capsular rents in the small-
PC rent was seen in ECCE (68.8%) followed by
incision group (6%) as compared with
Phacoemulsification (29.5%). This can also be
the phacoemulsification group (4%).7
attributed to a large number of ECCE (79.2%) being
At ASTEH once an intraoperative PC rent
done as compared to phacoemulsification (20.7%).
occurs it is managed by anterior vitrectomy and intra
The UK Cataract National Database of
ocular lens (IOL) implantation if sufficient capsular
Cataract Surgery reported a posterior capsular rupture
support is present. Otherwise a secondary AC or PC
rate of less than 4.2% in most institutions of UK.9
IOL is planned later on considering the status of the
Also in a multi-centre audit of 12 NHS Trusts,
eye. Most of the cases in the study were managed
posterior capsular rupture rate was found to be
efficiently with PC IOL implantation and only 11
1.92%.8 Comparing this data with the relatively high
cases were left aphakic. Ten of these were from
over all PC rupture rate observed at ASTEH there is a
ECCE and one from phacoemulsification. This
dire need to shift to the more advanced and safe
further confirms the lower rate of complications with
procedure of Phacoemulsification as eyes having
phacoemulsification making it a preferable procedure
posterior capsule rupture during cataract surgery have
along with other advantages of less time and better
a significant risk of reduced visual acuity and are 3.8
results postoperatively. Six of these aphakic cases
times more likely to have a final best spectacle
were from second year residents, none from third
corrected visual acuity of less than 6/12.9 With the
year and 3 from fourth year again stressing upon the
conversion from extracapsular extraction to
decrease in number of complications with improved
phacoemulsification, the outcomes of cataract
skill and experience.
surgery improve greatly and the risk of complications
Limitations of our study were: Limited study
fall4. This is in accordance with our study where a
period, unequal number of each year residents
low complication rate is observed in
performing the same surgeries, great disparity among
phacoemulsification alone. Further considering the
the total number of cases being done by each year of
year of residency maximum rent were observed in
residents, and no information about the preoperative
fourth year followed by second year which can again
risk factors for PC rent

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However, this data can be used for future
research and audit projects specially when very little
data is available from Pakistan and can be used to
assess the resident learning curve and compare the
resident faculty skills. Also cataract extraction is the
major surgical procedure being done so the rate of
complications, its management and the skill of
residents should be regularly assessed.
CONCLUSION
In conclusion it could be stated that there is a
relatively high rate of posterior capsule rupture in
ECCE procedures as compared to
phacoemulsification. PC rupture rate is directly
related to the procedure, being low for
phacoemulsification as compared to ECCE. PC
rupture rate is directly related to the skill and
expertise of the surgeon, being high for second year
residents as compared to third and fourth year
residents.
RECOMMENDATIONS
This study should be repeated to keep a check on the
rate of intra-operative cataract extraction
complications specific to each procedure type and
relating it to the year of residency. Resident learning
curve should also be assessed. The resources should
be redirected to make phacoemulsification as the
Address for Correspondence:
Dr. Tahira Ayub, Department of Medical Education, Foundation University Medical College, Rawalpindi-
Pakistan.
Email: drtahira85@gmail.com
306 http://www.jamc.ayubmed.edu.pk
J Ayub Med Coll Abbottabad 2015;27(2)
procedure of choice for cataract extraction.
Conflict of Interest: The authors have no conflict of
interest.
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